CurrentUnitedHealthcarePolicy N/A

Prior authorization form — injectable biologic therapy for Crohn's disease and ulcerative colitis

This document is a beneficiary prescriber prior authorization (PA) form used by UnitedHealthcare to request coverage for an injectable biologic for adults with Crohn's disease or ulcerative colitis. It collects patient, prescriber, and drug details and documents screening and prior treatment requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form — injectable biologic therapy for Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including diagnosis, TB and hepatitis B screening, prior Humira trial or contraindication, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2disease-specific sections

5screening/treatment questions

365max therapy days

1-855-258-1593PA Call Center

Coverage and Medical Necessity Criteria

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization form — injectable biologic therapy for Crohn's disease and ulcerative colitis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including diagnosis, TB and hepatitis B screening, prior Humira trial or contraindication, and prescriber signature.

SourceLink

On This Page

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Medical necessity criteria for injectable biologic PA

Covered when ALL of the following are met

Diagnosis: Beneficiary has a diagnosis of moderate to severe Crohn's disease or ulcerative colitis (as applicable)

Form requires prescriber to affirm diagnosis

Current biologic status: Beneficiary is not currently on another injectable biologic immunomodulator

Form asks prescriber to confirm current biologic use

TB screening: Beneficiary has been considered and screened for the presence of latent tuberculosis infection

Required screening prior to biologic therapy

Hepatitis B testing: Beneficiary has been tested with Hep B surface antigen (SAG) and core antibody (Core Ab)

Form requires documentation of Hep B testing

Prior therapy with Humira: Beneficiary has had a trial and failure of Humira or there is a documented clinical reason the beneficiary cannot try Humira

Step therapy expectation: trial/failure of Humira or contraindication satisfies this element

Administrative: Prescriber signature and complete beneficiary, prescriber, and drug information provided; length of therapy selected

Form includes mandatory prescriber signature and requires length of therapy selection

Required Actions, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Required for Injectable Biologics

Prior authorization is required for injectable biologic medications. Complete the provided prior authorization form to document diagnosis, screening, prior treatments, and requested drug details. Submit the prescriber and beneficiary identifying information and the requested length of therapy as indicated on the form.

Submit completed PA form prior to initiation of therapy
Call Pharmacy PA Call Center: 1-855-258-1593 if questions

Documentation Required

Required Form Fields

The PA form includes required beneficiary and prescriber fields. Missing or incomplete clinical fields may delay review or result in denial. Ensure the form includes diagnosis details, prior biologic use, screening results, and trial/failure documentation where applicable.

Beneficiary: name, ID #, date of birth, gender
Prescriber: name, NPI, requester contact name/phone
Drug details: drug name, strength, quantity per 30 days, requested length of therapy

Denial Risk

Missing Clinical Fields May Cause Denial

Failure to provide required clinical information (for example, documentation of moderate to severe disease, prior biologic therapy, TB and Hepatitis B screening results, and evidence of trial and failure of step-therapy agents) may cause denial. Attach clinical notes, prior treatment histories, and lab results to support the request.

Document diagnosis severity (eg, moderate to severe Crohn's disease or ulcerative colitis)
Report prior and current use of other injectable biologic immunomodulators
Provide TB screening and Hepatitis B (SAg and Core Ab) test results
Include documentation of trial and failure of Humira or a clinical reason Humira cannot be used

Step Therapy

Step Therapy Expectation Regarding Humira

Step therapy expectations: the form asks whether the beneficiary had a trial and failure of Humira (adalimumab) or provides a clinical reason why Humira is not appropriate. Provide clear documentation of the trial, duration, response, and reason for failure, or the contraindication/reason Humira cannot be used.

Answer the Humira trial/failure question on the form for Crohn's disease and ulcerative colitis sections
If Humira was tried, include dates, dose, and reason for discontinuation (lack of efficacy, intolerance, adverse event)
If Humira was not appropriate, document the clinical rationale

Background

This prior authorization form applies to adult patients with a diagnosis of moderate to severe Crohn’s disease or ulcerative colitis being considered for an injectable biologic immunomodulator. The prescriber must affirm the diagnosis and confirm the beneficiary is not currently on another injectable biologic, document screening for latent tuberculosis, document Hepatitis B surface antigen and core antibody testing, and indicate whether the beneficiary has had a trial and failure of Humira (adalimumab) or provide a clinical reason why Humira cannot be used.

Definitions

Moderate to severe Crohn's disease / ulcerative colitis — prescriber affirmations

Prescriber affirmation requiredPrescriber must confirm the beneficiary has the specified diagnosis and sign the form (signature line present)

Diagnosis severity indicationForm asks that beneficiary have a diagnosis of moderate to severe Crohn's disease or ulcerative colitis (checkbox question)

Biologic status confirmationPrescriber must indicate the beneficiary is not on another injectable biologic immunomodulator (yes/no)

Prior therapy with HumiraForm requires documentation whether beneficiary had a trial and failure of Humira or a clinical reason they cannot try Humira (yes/no)

Screening requirements documentedPrescriber must confirm latent tuberculosis screening and Hep B surface antigen and core antibody testing

OpenPayer

Prior authorization form — injectable biologic therapy for Crohn's disease and ulcerative colitis

Coverage and Medical Necessity Criteria

Coding and Therapy Duration Options

Required Actions, Documentation, and Step Therapy

Background

Definitions